Slide 1

Commissioned Corps of the U.S. Public Health Service Monrovian Medical Unit (MMU) Mission at Camp Eason (Margibi County, Liberia)

Slide 2

Obligatory Disclaimer This presentation is solely from a personal experience perspective; and does not represent the official positions or policies of the U.S. Public Health Services or U.S. Department of Health and Human Service.

Slide 3

Presentation Outline Share Ebola Response to Liberia A personal perspective Update on Global Movement to Preparedness Lessons are being learned Things are changing

Slide 4

U.S. Public Health Service Who Are We? A Uniformed Service comprised of 6,800 Officers under the direction of the U.S. Surgeon General, Dr. Vivek Murthy Comprised of: Physicians, Dentists, Nurses, Therapists, Pharmacists, Health Services, Environmental Health, Dietitians, Engineers, Veterinarians and Scientists.

Slide 5

U.S. Public Health Service The mission of the U.S. Public Health Service Commissioned Corps is to protect, promote, and advance the health and safety of our Nation. As America's uniformed service of public health professionals, the Commissioned Corps achieves its mission through: Rapid and effective response to public health needs Leadership and excellence in public health practices Advancement of public health science

Slide 6

Ebola The Background The 2014 Ebola outbreak is the largest in history and the first Ebola outbreak in West Africa. This unprecedented outbreak has affected multiple countries in and around West Africa, with the countries of Sierra Leone, Liberia and Guinea having been the hardest hit. Recognizing that the only way to eradicate the threat of Ebola in America and the world is to defeat it at its source, the U.S. has significantly ramped up efforts to fight the virus in West Africa.

Slide 7

United States Response U.S. Strategy POTUS: Ebola epidemic in W. Africa and the humanitarian crisis there is a top national security priority for the United States Strategy is predicated on four key goals: Strategy is predicated on four key goals: 1.Controlling the epidemic at its source in West Africa; 2.Mitigating second-order impacts, including blunting the economic, social, and political tolls in the region; 3.Engaging and coordinating with a broader global audience; and 4.Fortifying global health security infrastructure in the region and beyond.

Slide 8

Prior to Departure 65 Officers completed an intense 7-day training conducted by the Center for Disease Control and Prevention at FEMAs Center for Domestic Preparedness in Anniston, Alabama. A Total of 4 Teams deployed between Oct 2014 and May 2015. The MMU is now operated by the Liberian Government.

Slide 9

Monrovia Medical Unit Our mission was to provide hope through care to health care workers in Liberia who may have the Ebola virus disease and continue efforts with the Liberian and international partners to build capacity for additional care.

Slide 10

Monrovia Medical Unit (MMU) The MMU is a 25-bed Ebola Treatment Unit specifically designed to treat infected health care workers such as doctors and nurses who are at higher risk of infection, because they are in close, sustained contact with Ebola patients who are symptomatic and infectious.

Slide 11

Slide 12

Slide 13

Reference to the MMU Video Tour is available at: https://www.youtube.com/watch?v=bmyUb3 N5gAk https://www.youtube.com/watch?v=bmyUb3 N5gAk

Slide 14

Early Clinical Presentation Acute onset; typically 810 days after exposure (range 221 days) Signs and symptoms Initial: Fever, chills, myalgias, malaise, anorexia After 5 days: GI symptoms, such as nausea, vomiting, watery diarrhea, abdominal pain Other: Headache, conjunctivitis, hiccups, rash, chest pain, shortness of breath, confusion, seizures Hemorrhagic symptoms in 18% of cases Other possible infectious causes of symptoms Malaria, typhoid fever, meningococcemia, Lassa fever and other bacterial infections (e.g., pneumonia) all very common in Africa 14

Slide 15

Clinical Features Nonspecific early symptoms progress to: Hypovolemic shock and multi-organ failure Hemorrhagic disease Death Non-fatal cases typically improve 611 days after symptoms onset Fatal disease associated with more severe early symptoms Fatality rates of 70% have been reported in rural Africa Intensive care, especially early intravenous and electrolyte management, may increase the survival rate 15

Slide 16

Clinical Manifestations by Organ System in West African Ebola Outbreak Organ SystemClinical Manifestation GeneralFever (87%), fatigue (76%), arthralgia (39%), myalgia (39%) NeurologicalHeadache (53%), confusion (13%), eye pain (8%), coma (6%) CardiovascularChest pain (37%), PulmonaryCough (30%), dyspnea (23%), sore throat (22%), hiccups (11%) GastrointestinalVomiting (68%), diarrhea (66%), anorexia (65%), abdominal pain (44%), dysphagia (33%), jaundice (10%) HematologicalAny unexplained bleeding (18%), melena/hematochezia (6%), hematemesis (4%), vaginal bleeding (3%), gingival bleeding (2%), hemoptysis (2%), epistaxis (2%), bleeding at injection site (2%), hematuria (1%), petechiae/ecchymoses (1%) IntegumentaryConjunctivitis (21%), rash (6%) WHO Ebola Response team. NEJM. 2014 16

Slide 17

Examples of Hemorrhagic Signs Bleeding at IV Site Hematemesis Gingival bleeding 17

Slide 18

Laboratory Findings Thrombocytopenia (50,000100,000/ L range) Leukopenia followed by neutrophilia Transaminase elevation: elevation serum aspartate amino- transferase (AST) > alanine transferase (ALT) Electrolyte abnormalities from fluid shifts Coagulation: PT and PTT prolonged Renal: proteinuria, increased creatinine 18

Slide 19

EVD Summary The 2014 Ebola outbreak in West Africa is the largest in history and has affected multiple countries Think Ebola: U.S. healthcare providers should be aware of clinical presentation and risk factors for EVD Human-to-human transmission by direct contact No human-to-human transmission via inhalation (aerosols) No transmission before symptom onset Early case identification, isolation, treatment and effective infection control are essential to prevent Ebola transmission 19

Slide 20

MMU Team 1: Challenges Never been done before a U.S. Government asset transforming an Army MASH tent unit into an ebola treatment center. Difficult diagnosis without lab test results. Lack of a ready supply stream and equipment. Learning who the response partners were in country and how to work with them. Adjusting medical care standards based on environment and resources.

Slide 21

Innovation Required !!

Slide 22

MMU Team 1: Schedule Worked 2 months straight except for 2 days Hour 1 awake and get ready for commute Hour 2 Commute to MMU Hour 4-16 for 12-hour shift Hour 18 Commute to Lodging Hour 19 Fall asleep for a 5 hour nap Start all over again!

Slide 23

18 Guys in a tent

Slide 24

What did CAPT Bates do? Logistics Team Whatever the task of the moment demanded. Supply and Inventory control Infection control Safety Medical Lab Housekeeping Pharmacy Facilities and Supply Dietary Bug Control

Slide 25

Ebola Buster

Slide 26

Infection Control

Slide 27

1000 pounds of 65% HTH used

Slide 28

Biohazard Waste Process

Slide 29

How We Protected Ourselves Donning and Doffing Video Reference: https://www.youtube.com/watch?v=mfT9ipzt g5Y https://www.youtube.com/watch?v=mfT9ipzt g5Y

Slide 30

PPE Personal Protection Equipment

Slide 31

PPE

Slide 32

MMU Team 1: Outcomes The USPHS sent 65 clinicians, administrators, and support staff to assist in the response effort. Health care providers in Liberia now had a place to go if they contracted the ebola virus. The efforts of USAID, DoD, USPHS, Government of Liberia, International Partners, and NGOs built capacity for additional care in Liberia Over 100 providers from Africa were reported to have joined the effort in Liberia during our tour.

Slide 33

A Successful Mission and Safe Return

Slide 34

The Global Movement to Preparedness Lessons Learned Countries with weak health systems and few basic public health infrastructures cannot withstand sudden shocks to their society Preparedness swift action makes the difference No single control intervention is sufficient Community engagement is the linchpin for successful control

Slide 35

More Lessons Learned Operations: Put the needs of patients and communities at the core of any response. Evaluate and practice surge capacity Governance and Accountability A fast response will not happen without leadership. Set priorities based on what is needed on the ground. Research and Development Strengthen research and development systems focused on outcomes for the global public good.

Slide 36

Department of Health and Human Services July 1, 2015 DHHS launched a National Ebola Training and Education Center and funded 3 hospitals to train, prepare U.S. health care facilities for Ebola and other emerging threats. Regional Ebola treatments centers have been established. Evaluation of the national response planning, surge capacity, and supply stockpiles is ongoing.

Slide 37

Most Importantly Reactions and Responses must not be fear based !!

Slide 38

We Cant Rely on Batman

Slide 39

Future Challenges Focus science based public health over politics Global collaboration and commitments to strengthening public health infrastructures Commitment to collaborative and coordinated surge capacity Understanding the multi-factorial influencers of global public health challenges (political, economic, cultural, social determinants of health, funding, transportation, food/water, etc.) Reconciling health care responses with cultural and societal influencers Moving beyond disease specific preparedness to a global infectious and communicable disease preparedness and response capacity

Slide 40

A Patient Perspective

Slide 41

Recovery from Ebola Returning to the healthcare workforce

Slide 42

Other Information Link to news Article in Gazette Record, Saint Maries ID; regarding deployment to Liberia: http://www.stmariesid.com/fighting-ebola/ Web link to the Presidents recent update on the Ebola outbreak activities. http://www.c-span.org/video/?324305- 1/president-obama-remarks-combating-ebola http://www.c-span.org/video/?324305- 1/president-obama-remarks-combating-ebola

Slide 43

Slide 44

Contact Information CAPT Dale M. Bates U.S. Public Health Service Phone: 206-615-2497 (office in Seattle) Email: dbates@hrsa.govdbates@hrsa.gov Address: 23920 N Teddy Loop Rathdrum ID 83858